Provider Demographics
NPI:1366437840
Name:GUTIERREZ QUEHL, CARLOS R
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:GUTIERREZ QUEHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3226 REID DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2552
Mailing Address - Country:US
Mailing Address - Phone:361-853-4503
Mailing Address - Fax:361-853-4454
Practice Address - Street 1:3226 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2508
Practice Address - Country:US
Practice Address - Phone:361-888-6684
Practice Address - Fax:361-888-6686
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH33522085R0202X
TXH-3352208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB7663405Medicaid
86984RMedicare ID - Type Unspecified
E14171Medicare UPIN